CARE HOME ADULTS 18-65
Hascot House 243 Gleadless Road Sheffield South Yorkshire S2 3AL Lead Inspector
Mr Rob Curr Key Unannounced Inspection 21st September 2006 09:00 Hascot House DS0000002970.V300322.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Hascot House DS0000002970.V300322.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Hascot House DS0000002970.V300322.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Hascot House Address 243 Gleadless Road Sheffield South Yorkshire S2 3AL 0114 258 8895 0114 258 8895 none Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Valeo Limited ** Post Vacant *** Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Hascot House DS0000002970.V300322.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 9th February 2006 Brief Description of the Service: Hascot House is a detached domestic, two-storey style building providing care for nine adults. It is in a residential area of Sheffield with good access to public services and amenities (e.g. bus services, shops, libraries etc). It is well decorated, with single rooms and has a suitable number of lounges and dining rooms. The gardens are landscaped and it has a car park. Hascot House DS0000002970.V300322.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place between the hours of 9.00 am and 4:45 pm. The manager was not present when the inspection commenced. The Senior Project Worker on duty was extremely helpful and assisted the inspector throughout the inspection. The manager was present later during the inspection. The inspector was escorted on a partial tour of the building. A variety of policies, procedures, and records were checked. The residents were very helpful during the inspection process, offering ample opportunity to talk about what life was like at the home. In all – 5 residents and 3 staff members were spoken to. What the service does well:
All of the residents that met with the inspector were very happy at the home. One resident said that ‘nothing was too much trouble for the staff’. Cleanliness and hygiene standards in the house and kitchen areas were very good. Despite a number of residents having difficulties with personal hygiene there were no unpleasant odours. The staff and residents are to be commended for the cleanliness of the environment. Residents said that their relatives and friends were always made to feel welcome and that they could approach ‘all’ the staff if they wanted anything. The residents confirmed that they were fully involved in the admissions process including assessment and review. One person said that his relatives had been fully involved in the planning of his care needs. The dependency levels of the residents were monitored closely and appropriate staffing levels deployed when necessary. There were planned activities and a number of residents had been on individually planned holidays. There was a friendly and cheerful atmosphere promoted by the staff. The Manager (designate) and the staff team displayed a real commitment and enthusiasm to improve the service at Hascot House. Hascot House DS0000002970.V300322.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Hascot House DS0000002970.V300322.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hascot House DS0000002970.V300322.R01.S.doc Version 5.2 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 4. Quality in this outcome area was good. This judgement has been made using available evidence, talking with residents and including a visit to the home. Residents needs were assessed prior to admission and they were fully involved in the assessment process, so this ensured that the home was able to meet their needs. The staff said that the manager did not offer places to any individual whose needs they could not meet. The staff training plan was on target. EVIDENCE: Copies of full needs assessments were in the residents files. All the relevant information from the assessments had been built into the care plan. One resident said that she had been invited to view the home and attend a variety of meetings prior to them moving in. Staff training records indicated that they had undertaken relevant training. Hascot House DS0000002970.V300322.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 and 10. Quality in this outcome area was good. This judgement has been made using available evidence, talking with residents and including a visit to the home. The information within the care plans was very clear. The care planning process has empowered residents to make decisions about their lives with support from staff and others. Residents were involved in making decisions about their own lives, including holidays. People could choose their GP and could see them in private so that their privacy and dignity was respected. Risk assessments to minimise any risks associated with the resident’s lifestyles had been devised and had been regularly reviewed. Systems were in place to ensure that resident’s confidentiality was maintained in the home. Hascot House DS0000002970.V300322.R01.S.doc Version 5.2 Page 10 EVIDENCE: Five risk assessments were checked these contained clear information in order to minimise risks to residents and they had been reviewed on a regular basis. Peoples likes and dislikes in relation to food was recorded in care plans to ensure the staff knew the residents personal preferences. Residents meetings are organised regularly and the residents said, “I like to go to meetings with staff”, “we talk about holidays and outings”, the staff said this gave people the opportunity to be consulted on how the home was organised and run. The resident’s files were found to be stored securely and staff showed an awareness of confidentiality issues. The staff and residents said that they could see their files with staff support. Hascot House DS0000002970.V300322.R01.S.doc Version 5.2 Page 11 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17. Quality in this outcome area was good. This judgement has been made using available evidence, talking with residents and including a visit to the home. Some of the people have regular opportunities to access age, peer and culturally appropriate activities; others with higher support needs had limited opportunities. One person regularly accessed community day services and leisure activities. They were also supported to access other community facilities, such as shops, pubs and the local countryside etc. The residents were supported to have appropriate relationships with their peers and relatives. The staff showed respect for the people; in the way they spoke to and addressed them. The residents were observed to be offered choices and were supported to make everyday decisions. Meals were nutritious and balanced.
Hascot House DS0000002970.V300322.R01.S.doc Version 5.2 Page 12 EVIDENCE: Residents told the inspector that they took part in a range of leisure and daily activities on a regular basis. They said they had attended college courses. One resident said “I have had classes, “ I go out to the countryside with staff and to the pub for a drink, my key-worker takes me out”. This confirmed that residents were enabled to take part in their local community and to maintain relationships. One person told the inspector, “the staff are nice, and my key-worker is my favourite person”, and he said that he missed staff that had left. Staff were observed to treat people with respect as they knocked on doors before entering, addressed people by their preferred names and spoke of them with regard. There was a supply of nutritious food in the kitchen. This enabled people to make choices at each mealtime. The residents said they enjoyed the food on offer at the home. One of the residents said, “I like the food here”, and another person said, “I can contribute to my own cooking”. Hascot House DS0000002970.V300322.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area was good. This judgement has been made using available evidence, talking with residents and including a visit to the home. Staff were supportive and helped residents to choose their daily routines. Health needs were met and monitored and people were helped to identify their own needs through their involvement in care planning. This ensured the wellbeing of the residents The organisation had a medication policy. This was consistently implemented. A range of health care professionals visited the home to assist in meeting the needs of the residents. EVIDENCE: Staff provided sensitive and flexible personal support. Residents said they were encouraged to choose what time to get up and go to bed. The files checked had a section to record visits, treatment and identified future needs relating to healthcare professionals. Access to Psychologists etc, had been provided where there was an identified need.
Hascot House DS0000002970.V300322.R01.S.doc Version 5.2 Page 14 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area was good. This judgement has been made using available evidence, talking with residents and including a visit to the home. The residents were aware of how to make a complaint and were confident that they would be listened to. An adult protection procedure was in place to ensure people’s safety was promoted. EVIDENCE: The complaints procedure was available, which contained relevant information and provided the reader with details of who to contact outside the home, to ensure complaints were taken seriously. The home kept a record of complaints. Staff training in adult abuse had been identified within the training plan and a number of staff had already undertaking this training. The residents and staff stated that they had confidence in the homes manager. They said that she would listen and respond to any concerns they raised. One person said that he was positively encouraged to speak out at meetings. Everyone spoken to said they felt safe at the home. Hascot House DS0000002970.V300322.R01.S.doc Version 5.2 Page 15 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28 and 30. Quality in this outcome area was good. This judgement has been made using available evidence, talking with residents and including a visit to the home. The home was generally well maintained, well decorated and homely. The resident’s bedrooms were comfortable, individually personalised and furnished to meet their needs. The gardens area to the front of the house was in good order. Residents were seen enjoying he outside facilities throughout the day. EVIDENCE: An inspection of the environment showed that generally the home was clean, well maintained and provided homely and comfortable accommodation to meet the resident’s needs. A number of bedrooms were checked. They had all been decorated to meet the individual persons needs and reflected their individual tastes. Hascot House DS0000002970.V300322.R01.S.doc Version 5.2 Page 16 Continuous refurbishment that had taken place to improve the environment for the residents. Everyone said how happy they were with the improvements. Two residents said that the staff had worked ‘very hard to improve our home’. There were a number of minor repairs required to improve the environment. There was a clear recording system of the maintenance and repair needs. The laundry facilities in the house were sufficient to meet the resident’s needs. Hascot House DS0000002970.V300322.R01.S.doc Version 5.2 Page 17 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 and 36. Quality in this outcome area was good. This judgement has been made using available evidence, talking with residents and including a visit to the home. Sufficient staff were provided to meet the needs of the residents. The recommendation that 50 of the care staff team are qualified to National Vocational Qualifications (NVQ) level 2 had been achieved. The manager had clearly identified the training needs of the staff group. There were staff vacancies at the time of the inspection. EVIDENCE: The residents felt that there were enough staff on duty during the day and night to care for their needs. 4 people said that the staff were ‘very good’ and ‘nothing was too much trouble’. One service user said that he was interested n being involved with the recruitment process fro the staff team. This was discussed with the manager who showed a willingness to promote such practices. A group of staff are currently undertaking the NVQ at level 2 and some have registered to commence the training. Staff have also achieved level 3. Staff confirmed that they received more than 3 days paid training each year.
Hascot House DS0000002970.V300322.R01.S.doc Version 5.2 Page 18 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 42 and 43. Quality in this outcome area was adequate. This judgement has been made using available evidence, talking with residents and including a visit to the home. The manager has applied for registration with the Commission for Social Care Inspection. Quality assurance systems ensured that resident’s views, on all aspects of the home were included in developments and changes. A health and safety policy was in place. Staff had received appropriate training, and the recording of accidents and risk assessments were in place. EVIDENCE: The Manager has successfully completed the City & Guilds NVQ level 4 and is currently undertaking the Registered Managers Award. Hascot House DS0000002970.V300322.R01.S.doc Version 5.2 Page 19 The organisation carry out regular monitoring visits. The inspector noted that audits had been maintained in relation to: • • • • • Daily recordings Medication record sheets Fire records Residents finances Health & safety The Director of Care regularly informs the CSCI of the outcome of these visits. There was a regular fire drill. However, the manager needs to ensure that regular agency workers are included on the fire drill records. Hascot House DS0000002970.V300322.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 4 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 3 3 3 3 2 3 Hascot House DS0000002970.V300322.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA37 Regulation 8 Requirement The recently recruited manager should continue to register with the Commission for Social Care Inspection. All agency staff must be included in the fire drill records. Timescale for action 01/01/07 2 YA42 23 21/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA16 YA34 Good Practice Recommendations The plan for the manager to have a separate office to conduct private and confidential business should continue. Consideration should be given to involving residents in the recruitment process. Hascot House DS0000002970.V300322.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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